There was an excellent response to this exercise which suggested that not only are most readers familiar with patients with hearing impairment, but recognise its significance upon the lives of sufferers.
You were asked the following questions:
A 78-year-old man attends for a routine eye examination. During your first conversation with him, you suspect he may have a hearing impairment. Discuss the following;
- What are the typical ways a hearing impairment becomes apparent?
- Is it your responsibility to mention your suspicions?
- What might be your advice to the patient if you feel help might be appropriate related to his hearing impairment? In your discussion, please state any service provision appropriate to the location of your practice.
Signs of Impairment
Most respondents recognised that there are a whole range of verbal and non-verbal indicators of hearing loss. A typical response list was, ‘The patient may ask for things to be repeated. His answers may not make sense or not appear to be answering the question. He may misinterpret instructions. Look for gestures such as cupping the hand behind the ear, leaning forward, looking intently at the mouth of the person speaking. The patient may speak louder than one might expect. Some hearing impaired patients may not respond immediately when called for their appointment. Support staff may be able to alert the practitioner if a particular patient had difficulty conversing on the telephone.’
Another suggested, ‘The gentleman in question would have gradually noticed his ability to hear higher pitched sounds. Over time, he would also have noticed more difficulty with lower frequencies, and generally noticed that speech is loud enough, but not clear. The most common reason for hearing loss in the elderly is loss of nerve cell hairs in the cochlea. This gentleman may also be on medication which could be a contributory factor. Should the gentleman be attending with a relative, we can ask whether these symptoms have been relevant for some time. We need to involve the gentleman at all times and sympathetically ask the relevant questions as to general health, last visit to GP, and any build-up of wax in ear.’
A number of you mentioned some indicators that might become apparent in real life situations, such as, ‘Turning the TV louder than others want it, finding that others mumble, struggling to hear well on the phone, struggling to hear in noisy environments, finding it hard to keep up with conversations. They may also experience loudness recruitment, which is when someone finds it difficult to cope with loud noises and sometimes complain they can’t hear you when at other times they complain you are shouting.’ Generally, most are aware that patients may experience ‘anger, anxiety and frustration due to their hearing.’
Responsibility
Not a single respondent suggested it was outside the responsibility of the eye care professional to address suspected hearing loss. Typical among answers given was, ‘if I felt my patient had some form of hearing impairment I would have to mention it. I feel it would be my duty to help as much as I could.’
A more thorough answer was, ‘As a healthcare professional I think it is our responsibility to care for people, often hearing and sight impairment can go hand in hand so, in a sensitive way, I think we should gently question the patient and give support and give them the tools to set the ball rolling to gain better hearing. Sight and hearing problems can lead to depression, so it is important people get the right support and help. It is also advisable not to mention deaf or deafness as people who are new to hearing loss can be sensitive to this (although people actually in the deaf community are not).’
Support and help
Approximately half of responses mentioned the availability of a free hearing test. ‘As a dispensing optician if I felt someone might have a hearing loss I would gently offer them the opportunity to have a free screening done, if that screening establishes that the patient has indeed missed some sounds I would then take the opportunity to discuss hearing loss and treatment in more detail.’ This reflected the increasing availability of hearing care services within community eye care practices, and many of you work in clinics offering free screening for the over-40s.
I particularly liked the following response: ‘Initially we could suggest that they speak to their GP or attend a hearing specialist. The GP can refer to the hospital for help within the NHS. They have some pretty advanced and discreet hearing aids and a ‘walk in’ service for any general problems. They may have to push for a referral as 45% of people who go to the GP with hearing problems are not referred! On a more practical level, there is a local support group in Blackpool called Blackpool Fylde and Wyre Society for the deaf, they meet every two weeks for support, chats and socialising. They also run lip reading classes. Also, a very helpful website, ‘Action on Hearing Loss’. From experience, a whole new world opens up once you have the correct help for your hearing, often you do not realise what you have been missing! I find having this problem myself makes chatting to patients easier.’